Coding, medical billing and the current use of my MD.

     As some of you regular readers may know, I am an MD, retired, but I still do have those letters after my name. Now I am having experiences in the medical field from the other side of the check in counter. That is -I have been a patient several times in the last 1 year. What these experiences have led me to believe is that you need an MD to decipher the EOBs (explanation of benefits) that come in the mail after a medical visit. AND more importantly you need an MD to know what was billed and to go to battle to get the coding corrected so that your insurance or Medicare will cover what it is supposed to cover.
     I will tell you about my specific coding blunders that I had to use my medical knowledge to fight. I think two of them are very common and should be argued with your doctor if you detect them.
     The biggest blunder and hardest to correct when I had my outpatient day surgery on my arm to remove the melanoma and at the same time, do a sentinel node biopsy. Of course, in preparation for my surgery, the anethesia resident came to my day surgery room to review my medical history, and discuss the anesthesia she was going to give me. And she started my IV. Standard practice calls for an intracath in the vein (a plastic sheath threaded into the vein, rather than just a small metal needle) because with an intracath the IV site is more stable and reliable even if the hand  is moved around during surgery. But the drawback is that it is more painful to place an intracath into the vein. So the anesthesiologist first infliltrated some lidocaine (xylocaine)  with a fine needle as a pain killer around the vein she planned to use for the IV. (As an aside, she couldn't get that IV started; the vein collapsed. So she had to try two different times in other veins and I didn't have the benefit of the pain killer for those veins anyway. But that is beside the point.) When my bill came back after surgery, it listed two drugs that were administered under a class called "self-administered pharmaceutical agents." I had heard about this one before. I was given a Tylenol with codeine pill after the surgery while still in the recovery day surgery room. Apparently Medicare and insurance do not cover oral meds given in these circumstances because they can be taken by the patient without the need for a nurse. So a charge is administered for these meds that is often quite large. I was charged $35.00 for that single pain pill. Medicare tells you that you could get a prescription through your doctor prior to the surgery and then take that pain pill at the day surgery site on your own and avoid that charge. However, it is also a known protocol that the day surgery people will not let you bring any of your own meds with you nor will they let you take them without a direct order that you can take your own meds, from your doctor. By the time you need this order, your doctor is long gone. So this issue is a well-known Catch-22 and you basicly just have to pay the large fee for that single pain pill that they administer. But in my case, along with that charge for the Tylenol with codeine, there was a charge for another self-administered drug, denied by Medicare. First I had to call Medicare to see what the code and denial applied to. Then I had to call the hospital and have someone look at my chart to see what that other self-administered drug I could have been given under that code. I didn't recall anything else. And it couldn't have been self-administered if I was already under the anesthetic. A couple phone calls showed that it was lidocaine. It was that infiltrated lidocaine used to deaden the site where my IV was to be started. Well, I certainly didn't administer that to myself with a needle from a vial of the medication. Clearly the use of this medication had been miscoded, denied by Medicare, and I was being charged about $65.00 for this, when it should have been part of the whole procedure and paid for by my insurance. Now that I had it sorted out from the codes, I had to call back the billing of the hospital, and tell them what needed to be changed so that that charge would be resubmitted and would apparently be paid for. It took about 2 months but it worked.
      The other two instances were pre op lab blood tests that were coded as routine. This happened when the surgeon ordered preops for my melanoma surgery and it happened again when my gastroenterologist ordered a pre procedure potassium and metabolic panel before my colonoscopy. In both cases the procedure was being done for diagnostic reasons: melanoma in case of that surgery, and symptoms before the colonosocpy which had to be coded using the number for the symptoms, not as routine. Medicare is very clear that it does not pay for routine tests. It now will pay for a routine screening colonoscopy but apparently will not pay for the labs that your doctor requires you to have before the screening procedure. Mine was being done due to some vague symptoms so those needed to be coded properly so that Medicare would pay also for the pre procedure labs. It took a phone call to the billing for my clinic to find out what the lab was and how it was coded; then a call to Medicare again to affirm that they would not pay for the tests under this code. It was a V code: V76.23. All V codes are routine tests done for some screening reason. That immediately told this MD that they had coded the lab tests as routine and they would not be paid for until we got those codes changed. Now I had to get a message back to my gastroenterologist directly for him or his assistant to change the code and replace it with a code that means "change of bowel habits" the symptom that required the colonoscopy, and then resubmit that to Medicare. That is now in the process of happening and I assume it will take a couple months for this to get straightened out. The total cost to be saved here was $88.00 for the lab test, and $24.00 for drawing the blood for the lab test.
     You see! You need an MD to be sure that you are billed properly and receive payment for all the medical items that you are entitled to. Most people would probably just pay the bill. But sometimes these errors add up to several hundred dollars or more. Be forewarned and be alert; examine your EOB carefully and call to ask questions that you don't understand.